Less and less limb loss: But uphill battle still awaits, experts say

Lower extremity amputation (LEA) rates in the US continue to fall, according to an analysis published in July that confirms earlier research demonstrating a steady decline beginning in the 1990s.

Researchers from the University of Iowa in Iowa City looked at all claims for LEA in the Medicare population from 2000 to 2010. They reported a 28% overall decrease in LEA, a 47% decrease in amputations at the upper and lower leg level, and a 35.5% decrease in those at the midfoot. Amputation at the partial toe level increased 24%, the only level for which amputation rates rose during the study period, according to the report published in Foot & Ankle International. The findings are consistent with those of a 2012 article published in Diabetes Care.

“We will need to pay more attention to how orthoses and shoe modifications can be used to improve quality of life and reduce ulcer risk for patients with more distal amputations,” said Phisitkul, assistant clinical professor in the University of Iowa’s Department of Orthopaedics and Rehabilitation.

The researchers also found a 143.3% increase in rates of selected treatments for diabetic foot ulcers (Achilles tendon release, gastrocnemius recession, tendon lengthening or shortening, and total contact casting).

“This study indicates clinical and research efforts show promising signs in controlling LEA rates,” said Phisitkul, who stressed that the treatments reviewed in the study don’t tell the whole story, and many other factors have likely played a role in decreasing LEA rates.

“Continued success in preserving limbs and function in our aging population will be impossible without an integrated, multidisciplinary approach involving patient education, preventive care, early detection, and cost-effective treatments,” he said.

David G. Armstrong, DPM, MD, PhD, agreed the explanation for falling rates is multifaceted. And, like Phistikul, who called the challenge of caring for vulnerable patients “an uphill battle,” Armstrong believes that, with a growing at-risk population, now is not the time for complacency.

“A few years ago our group presented a talk called ‘Declining amputation rates in the US: a day at the beach or the calm before the next big wave,’ and the answer, I think, is that it’s both,” said Armstrong, who is professor of surgery and codirector of SALSA (Southern Arizona Limb Salvage Alliance) at the University of Arizona Medical Center in Tucson.

He noted that while changes in the definition of diabetes in the mid-1990s brought many new-onset patients into the population, increasing the denominator and thus lowering the percentage of LEAs, improved care of diabetic foot ulcers has also played a significant role.

“The good news is that we may be picking these things up earlier, and we’re going after them medically, mechanically, surgically,” he said. “What I would caution [about] would be for us to think that all is well. Because all is not well. We’re seeing more ulcers in patients because people are getting older and have longer-term complications with diabetes. We know a lot of ulcers get infected, and ultimately, many lead to amputation.”

Continuing declines in LEA rates are not a given, he said, pointing to data he presented in June at the American Diabetes Association Symposium in Chicago.

“In 2009, reimbursement for podiatric care was eliminated from Arizona’s Medicaid budget. We were surprised to find that, almost immediately, we saw an effect,” said Armstrong, who looked at rates of diabetic foot infection from 2006 to 2010.

Specifically, after changes went into effect, Armstrong and colleagues found a 37% increase in hospital admissions; a 30% increase in length of stay; a 45% increase in average charges, and a 50% increase in severe aggregate outcomes—death, amputation, sepsis, and surgical complications.

“Though there are some signs that point to that not being true, I’m an optimist,” he said. “I still believe we’re on a really good track, but we have to be aware there’s a wave gathering, and we’re either going to surf that wave or we’re going to be overtaken by it. And I’d rather prepare my surfboard right now.”